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This is a conceptual overview of a premeeting institute (PMI) I presented at the 39th International Society for Traumatic Stress Studies (ISTSS) annual meeting in November 2023 entitled, “A Functional Approach to Repairing Moral Injury and Traumatic Loss in Context: Evidence, Change Agents, Clinical Strategies, and Lessons Learned.” This paper was invited by the co‐chairs of the Scientific Program Committee, Isaac Galatzer‐Levy and Katharina Schultebraucks. I first describe the aims of the PMI and then summarize the foundational assumptions that led me to expand adaptive disclosure and create adaptive disclosure–enhanced (AD‐E). The foundational assumptions are that (a) moral injury is a unique measurable potential clinical problem, (b) moral injury damages the sustaining building blocks to personal and collective humanity, and (c) repairing moral injury requires corrective humanizing and virtuous experiences and connections. I then provide an overview of AD‐E and describe two new change agents— loving–kindness meditation and letter writing—that augment the original AD in service of promoting corrective experiences in the social world that are valued, valuing, and promote the experience of belonging. [ABSTRACT FROM AUTHOR]

Objective: This is a randomized controlled trial (NCT03056157) of an enhanced adaptive disclosure (AD) psychotherapy compared to present-centered therapy (PCT; each 12 sessions) in 174 veterans with posttraumatic stress disorder (PTSD) related to traumatic loss (TL) and moral injury (MI). AD employs different strategies for different trauma types. AD-Enhanced (AD-E) uses letter writing (e.g., to the deceased), loving-kindness meditation, and bolstered homework to facilitate improved functioning to repair TL and MI-related trauma. Method: The primary outcomes were the Sheehan Disability Scale (SDS), evaluated at baseline, throughout treatment, and at 3- and 6-month follow-ups (Brief Inventory of Psychosocial Functioning was also administered), the Clinician-Administered PTSD Scale (CAPS-5), the Dimensions of Anger Reactions, the Revised Conflict Tactics Scale, and the Quick Drinking Screen. Results: There were statistically significant between-group differences on two outcomes: The intent-to-treat (ITT) mixed-model analysis of SDS scores indicated greater improvement from baseline to posttreatment in the AD-E group (d = 2.97) compared to the PCT group, d = 1.86; −2.36, 95% CI [−3.92, −0.77], t(1,510) = −2.92, p <.001, d = 0.15. Twenty-one percent more AD-E cases made clinically significant changes on the SDS than PCT cases. From baseline to posttreatment, AD-E was also more efficacious on the CAPS-5 (d = 0.39). These differential effects did not persist at follow-up intervals. Conclusion: This was the first psychotherapy of veterans with TL/MI-related PTSD to show superiority relative to PCT with respect to functioning and PTSD, although the differential effect sizes were small to medium and not maintained at follow-up. What is the public health significance of this article?: Warzone-related posttraumatic stress disorder (PTSD) is a highly multifarious clinical problem, partly because combat trauma can entail extensive traumatic loss and moral injury, either from personal transgressive acts or bearing witness to or being victimized by others' transgressions. Adaptive disclosure (AD) is an evidence-based psychotherapy that was designed to help service members and veterans with war-related PTSD. We applied lessons learned from previous research on AD and enhanced AD to better help war veterans with loss- and moral-injury-related PTSD. We compared the enhanced AD (AD-E) with present-centered therapy (PCT) in a clinical trial of 174 veterans with PTSD. We found AD-E to be superior to PCT with respect to helping veterans function better and in terms of reducing PTSD symptom burden. [ABSTRACT FROM AUTHOR]

Copyright of European Journal of Psychotraumatology is the property of Taylor & Francis Ltd and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Copyright of European Journal of Psychotraumatology is the property of Taylor & Francis Ltd and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Cognitive processing therapy (CPT) is an effective treatment for posttraumatic stress disorder (PTSD); however, some patients do not improve to the same extent as others. It is important to understand potential factors that can be modified for better patient outcomes. This clinical trial implemented a three‐arm, equipoise‐stratified randomization design to allow for the accommodation of patient preference before randomization to one of three CPT treatment modalities: in‐home, in‐office, or telehealth. This study examined whether satisfaction with the modality, perceived stigma, expectations of therapy, and credibility of the therapist differed between modalities and whether these factors impacted treatment outcomes. We hypothesized that the contributions of these variables would depend upon whether participants opted out of any treatment arms and that these factors would predict treatment outcomes. Participants who endorsed less perceived stigma demonstrated larger reductions in PTSD symptom severity than those with similar levels of perceived stigma in the telehealth and in‐office conditions, η2 =.12–.18. Participants who endorsed lower satisfaction with their treatment modality and were assigned to the in‐home condition experienced larger PTSD symptom reductions than those with similar dissatisfaction in the telehealth and in‐office conditions, η2 =.20. The results show the robustness of evidence‐based therapies for PTSD given that dissatisfaction did not impede treatment success. In addition, they demonstrate that it is important for clinicians to address stigma before initiating evidence‐based therapies for PTSD. Strategies to address these factors are discussed. [ABSTRACT FROM AUTHOR]

Introduction: Many military service members with PTSD do not receive evidence-based specialty behavioral health treatment because of perceived barriers and stigma. Behavioral health providers in primary care can deliver brief, effective treatments expanding access and reducing barriers and stigma. The purpose of this randomized clinical trial was to determine if a brief cognitive-behavior therapy delivered in primary care using the Primary Care Behavioral Health model would be effective at reducing PTSD and co-occurring symptoms. Method: A total of 67 service members (50 men, 17 women) were randomized to receive a brief, trauma-focused intervention developed for the primary care setting called Prolonged Exposure for Primary Care (PE-PC) or a delayed treatment minimal contact control condition. Inclusion criteria were significant PTSD symptoms following military deployment, medication stability, and interest in receiving treatment for PTSD symptoms in primary care. Exclusion criteria were moderate or greater risk of suicide, severe brain injury, or alcohol/substance use at a level that required immediate treatment. Assessments were completed at baseline, posttreatment/postminimal contact control, and at 8-week and 6-month posttreatment follow-up points. Primary measures were the PTSD Symptom Scale-Interview and the PTSD Checklist--Stressor-Specific. Results: PE-PC resulted in larger reduction in PTSD severity and general distress than the minimal contact control. Delayed treatment evidenced medium to large effects comparable to the immediate intervention group. Treatment benefits persisted through the 6-month follow-up of the study. Discussion: PE-PC delivered in integrated primary care is effective for the treatment of PTSD and co-occurring symptoms and may help reduce barriers and stigma found in specialty care settings. Keywords: primary care behavioral health, posttraumatic stress disorder, randomized clinical trial, Posttraumatic stress disorder (PTSD) is a debilitating and costly mental health issue (Greenberg et al., 1999; Hoge, Terhakopian, Castro, Messer, & Engel, 2007). RAND reported an estimated 2-year cost of [...]

Although the disclosure of traumatic experiences is believed to influence trajectories of post-trauma recovery, less is known about individual differences that affect survivors' motivation to share. The current project describes the development and evaluation of the Disclosure Expectancy Scale (DExS), a novel instrument intended to assess survivors' expectations about the potential risks and benefits of disclosure. Items targeting both positive and negative expectancies were generated based on existing research and the authors' clinical experience with various survivor populations. Preliminary analyses in trauma-exposed undergraduates (N = 359) offer support for hypothesized positive and negative expectancy dimensions with evidence for the convergent and discriminant validity of scores. Subsequent evaluation in active-duty, help-seeking military personnel (N = 35) provides further evidence of validity based on correlations with relevant clinical measures. A final regression demonstrating unique effects of initial disclosure expectancies on post-traumatic stress disorder (PTSD) severity following trauma-focused treatment highlights the predictive validity of DExS scores. [ABSTRACT FROM AUTHOR]

Insomnia and nightmares are common in patients with posttraumatic stress disorder (PTSD). They are associated with worse psychological and physical health and worse PTSD treatment outcomes. In addition, they are resistant to PTSD treatments, which do not typically address sleep disorders. Cognitive behavioral therapy for insomnia and nightmares (CBT‐I&N) and cognitive processing therapy (CPT) for PTSD are first‐line treatments, but limited evidence exists guiding the treatment of individuals with all three disorders. The current study randomized U.S. military personnel (N = 93) to one of three conditions: CBT‐I&N delivered before CPT, CBT‐I&N delivered after CPT, or CPT alone; all groups received 18 sessions. Across groups, participants demonstrated significantly improved PTSD symptoms. Because the study was terminated prematurely due to challenges with recruitment and retention, it was underpowered to answer the initially intended research questions. Nonetheless, statistical findings and relevant clinically meaningful changes were observed. Compared to participants who received CPT alone, those who received CBT‐I&N and CPT, regardless of sequencing, demonstrated larger improvements in PTSD symptoms, d = −0.36; insomnia, d = −0.77; sleep efficiency, d = 0.62; and nightmares, d = −.53. Compared to participants who received CBT‐I&N delivered before CPT, those who received CBT‐I&N delivered after CPT demonstrated larger improvements in PTSD symptoms, d = 0.48, and sleep efficiency, d = −0.44. This pilot study suggests that treating comorbid insomnia, nightmares, and PTSD symptoms results in clinically meaningful advantages in improvement for all three concerns compared to treating PTSD alone. [ABSTRACT FROM AUTHOR]

The authors examined heterogeneity in posttraumatic stress disorder (PTSD) symptom presentation among veterans (n = 335) participating in the clinical interview subsample of the National Vietnam Veterans Readjustment Study. Latent class analysis was used to identify clinically homogeneous subgroups of Vietnam War combat veterans. Consistent with previous research, three classes emerged from the analysis, namely, veterans with no disturbance (61.4% of the cohort), intermediate disturbance (25.6%), and pervasive disturbance (12.5%). The authors also examined physical injury, war-zone stressor exposure, peritraumatic dissociation, and general dissociation as predictors of class membership. The findings are discussed in the context of recent conceptual frameworks that posit a range of posttraumatic outcomes and highlight the sizable segment of military veterans who suffer from intermediate (subclinical) PTSD symptoms. (Contains 3 tables and 1 figure.)